﻿<%@ Page Title="" Language="C#" MasterPageFile="~/Site.Master" AutoEventWireup="true"
    CodeBehind="form-validation.aspx.cs" Inherits="Dala.Samples.Form_Validation_Jquery.form_validation" %>

<asp:Content ID="Content1" ContentPlaceHolderID="HeadContent" runat="server">
    <link href="css/default.css" rel="stylesheet" type="text/css" />
    <link href="css/text.css" rel="stylesheet" type="text/css" />
    <link href="css/layout.css" rel="stylesheet" type="text/css" />
    <script src="js/form-validation.js" type="text/javascript"></script>
    <script src="js/jquery.maskedinput.js" type="text/javascript"></script>
</asp:Content>
<asp:Content ID="Content2" ContentPlaceHolderID="MainContent" runat="server">
    <div class="enroll-form-wrapper yourInfo">
        <h2 class="title-02">
            Please tell us about yourself.</h2>
        <div class="clearfix">
            <div class="required-wrap-01 right-space">
                <input type="text" class="form-input-medium" value="First Name" id="txtFirstName"
                    autocomplete="off" onclick="clearTextHere(this, 'First Name')" tabindex="1" onblur="resetText(this, 'First Name')"
                    onfocus="clearTextHere(this, 'First Name')" />
                <span></span>
            </div>
            <div class="required-wrap-01">
                <input type="text" class="form-input-medium form-input-medium-01" value="Last Name"
                    id="txtLastName" onclick="clearTextHere(this, 'Last Name')" tabindex="2" autocomplete="off"
                    onblur="resetText(this, 'Last Name')" onfocus="clearTextHere(this, 'Last Name')" />
                <span></span>
            </div>
        </div>
        <div class="clearfix">
            <div class="required-wrap-01 right-space">
                <input type="text" class="form-input-medium" value="Address 1" id="txtAddress1" onclick="clearTextHere(this, 'Address 1')"
                    tabindex="3" autocomplete="off" onblur="resetText(this, 'Address 1')" onfocus="clearTextHere(this, 'Address 1')" />
                <span></span>
            </div>
            <div class="required-wrap-01">
                <input type="text" class="form-input-medium  form-input-medium-01" value="Address 2 (Optional)"
                    id="txtAddress2" onclick="clearTextHere(this, 'Address 2 (Optional)')" tabindex="4"
                    autocomplete="off" onblur="resetText(this, 'Address 2 (Optional)')" onfocus="clearTextHere(this, 'Address 2 (Optional)')" />
                <span></span>
            </div>
        </div>
        <div class="clearfix">
            <div class="required-wrap-01 right-space">
                <input type="text" class="form-input-medium" value="City" id="txtCity" onclick="clearTextHere(this, 'City')"
                    tabindex="5" autocomplete="off" onblur="resetText(this, 'City')" onfocus="clearTextHere(this, 'City')" />
                <span></span>
            </div>
            <div class="required-wrap-01 right-space" ng-model="UserCtrl">
                <select class="form-dropdown-small" id="ddlState" tabindex="6">
                    <option value="null">State</option>
                    <option ng-repeat="state in stateList" value="{{state.ShortName}}">{{state.LongName}}</option>
                </select>
                <span></span>
            </div>
            <div class="required-wrap-01">
                <input type="text" class="form-input-small" value="Zip" id="txtZip" onclick="clearTextHere(this, 'Zip')"
                    tabindex="7" autocomplete="off" onblur="resetText(this, 'Zip')" onfocus="clearTextHere(this, 'Zip')" />
                <span></span>
            </div>
        </div>
        <div class="clearfix">
            <div class="required-wrap-01 right-space">
                <input type="text" class="form-input-medium " value="Phone Number" id="txtPhone"
                    onclick="clearTextHere(this, 'Phone Number')" tabindex="8" autocomplete="off"
                    onblur="resetText(this, 'Phone Number')" onfocus="clearTextHere(this, 'Phone Number')" />
                <span></span>
            </div>
            <div class="form-input-medium-01 input-wrapper required-wrap-01">
                <select id="ddlPhoneType" class="form-dropdown-large" tabindex="9">
                    <option value="">Phone Type</option>
                    <option value="Home">Home</option>
                    <option value="Mobile">Mobile</option>
                    <option value="Work">Work</option>
                </select>
                <span></span>
            </div>
        </div>
        <div class="clearfix">
            <div class="required-wrap-01 right-space">
                <span class="input-wrapper right-space">
                    <input type="text" class="form-input-medium " value="Email" id="txtEmailPersonal"
                        onclick="clearTextHere(this, 'Email')" tabindex="10" autocomplete="off" onblur="resetText(this, 'Email')"
                        onfocus="clearTextHere(this, 'Email')" />
                    <span></span>
                    <div class="tool-icon-wrap">
                        <div class="tooltip-cq dummyEmail" style="display: none">
                            Please Enter Your Valid Personal Email Address <span class="tooltip-arrow"></span>
                        </div>
                        <a id="tooltipEmail" href="javascript:void(0)" class="question-icon tooltipEmail">
                        </a>
                    </div>
                </span>
            </div>
            <div class="required-wrap-01">
                <input type="text" class="form-input-medium" value="DOB: MM/DD/YYYY" id="txtDOBPersonal"
                    autocomplete="off" onclick="clearTextHere3(this, 'DOB: MM/DD/YYYY')" onblur="resetText3(this, 'DOB: MM/DD/YYYY')"
                    onfocus="clearTextHere3(this, 'DOB: MM/DD/YYYY')" tabindex="11" />
                <span></span>
            </div>
        </div>
        <div class="clearfix">
            <div class="required-wrap-01">
                <span class="input-wrapper right-space">
                    <input type="text" name="fake_pass" class="form-input-medium" id="fake_pass1" value="Password for Your Account"
                        style="display: none" tabindex="12" />
                    <input type="password" class="form-input-medium" name="real_pass" id="txtPassword1"
                        tabindex="12" />
                    <%--<input type="text" class="form-input-medium" value="Password for Your Account" id="txtPassword1" autocomplete="off" tabindex="10" onclick="clearTextHere(this, 'Password for Your Account')"
                                    onblur="resetText(this, 'Password for Your Account')" onfocus="clearTextHere(this, 'Password for Your Account')" />--%>
                    <span></span><span class="tool-icon-wrap">
                        <div class="tooltip-cq dummyPassword" style="display: none">
                            Password must be at least 8 characters, no more than 12 characters, and must include
                            at least one upper case letter, one lower case letter, and one numeric digit. <span
                                class="tooltip-arrow"></span>
                        </div>
                        <a id="tooltipPassword" href="javascript:void(0)" class="question-icon tooltipPassword">
                        </a></span></span>
            </div>
            <div class="required-wrap-01">
                <input type="text" name="fake_pass" class="form-input-medium form-input-medium-01"
                    id="fake_pass2" value="Re-enter password" style="display: none" tabindex="13" />
                <input type="password" class="form-input-medium form-input-medium-01" name="real_pass"
                    id="txtPassword2" tabindex="13" />
                <%--<input type="text" class="form-input-medium" value="Re-enter password" id="txtPassword2" autocomplete="off" onclick="clearTextHere(this, 'Re-enter password')"
                                onblur="resetText(this, 'Re-enter password')" onfocus="clearTextHere(this, 'Re-enter password')" tabindex="11" />--%>
                <span></span>
            </div>
        </div>
        <span id="spanPasswordDoNotMatch"></span>
        <br class="clear" />
        <span>
            <input id="cbxTermsandConditions" type="checkbox" tabindex="15" /></span>
        <label class="en-label">
            I agree to the CaregiverHQ <a class="enroll-link" href='<%= ResolveUrl("~/terms-conditions")%>'
                target="_blank">Terms of Use</a>.</label>
        <span id="spanTermsandConditions"></span>
        <br class="clear" />
       <a href="javascript:void(0);" class="darkseagreen float-r submitPersonalInfo" onclick="javascript:return SavePersonalInformation();"
            tabindex="17">Save & Continue</a>
    </div>
</asp:Content>
